Workshop on Positron Emission Mammography
                       1 and 2 July, 2002
                        Lisbon, Portugal
---------------------------------------------------------------------
           RESERVATION FORM  -  HOTEL IBIS LIBERDADE
---------------------------------------------------------------------

FAMILY NAME: _____________________________________________________

FIRST  NAME: _____________________________________________________

INSTITUTION: _____________________________________________________

    ADDRESS: _____________________________________________________

             _____________________________________________________

      PHONE: _____________________________________________________

  FACSIMILE: _____________________________________________________


  (TYPE AN  "X"   IN THE SPACES CORRESPONDING TO YOUR CHOICES)


 Please book me a  ___ Single Room   (57 Euro/day)

                   ___ Double Room   (57 Euro/day)

                                     (breakfast 4 Euro/person)

 Date of arrival: 2002/____/___  Date of departure: 2002/____/___


    ___Visa   ___Eurocard  ___Mastercard  ___American Express 

    Credit card number: _____________________________________

      Credit card name: _____________________________________

           Expiry date: ____/___    (e.g. 11/00)

    Signature:  _____________________________________________


---------------------------------------------------------------------
 PRINT and send by FAX to    HOTEL IBIS LIBERDADE
                             R. Barata Salgueiro, 53
	                     1250-043 Lisboa, Portugal

       Fax: +351-21-330-0630    Tel: +351-21-330-0631
---------------------------------------------------------------------